Gupta AS

Cesarean delivery rates are rising globally. WHO recommends the optimal incidence to remain between 10 to 15% or extended to 20% for adequate prevention of the mother and the child and to prevent severe maternal morbidity and improve neonatal outcome. However, facts indicate a much higher incidence of cesarean births. In private sectors incidence has touched almost 70% and in some hospitals in Brazil the incidence has touched 100%. On an average 1 out of 3 or 1 out of 2 women give birth by cesarean section.
Current pregnancy cesarean births are associated with post operative postpartum hemorrhage, hollow organ injuries, anesthesia complications, infectious morbidity that includes superficial and deep wound infections, thromboembolic phenomena and even mortality.
Post cesarean section wound infection can cause severe morbidity and even mortality. Obese women, women in prolonged labor, PROM, poor aseptic techniques, uncontrolled diabetes, increased operative time and excessive blood loss, are all factors that predispose to cesarean section infectious morbidity. Nosocomial infections, cross infections lead to serious infections. E. Coli and staphylococcus aureus are the commonest organisms isolated. Reported incidence of post operative sepsis after cesarean section that includes major causes like pelvic infections, deep incision sepsis, or minor like superficial wound sepsis, febrile morbidity or catheter associated urinary tract infection ranges from 3.15% to 35.7%.
Superficial wound infections are commonly seen. Deep incision sepsis is not a common feature. However, if the uterine incision gets infected and breaks down then it can lead to pelvic or generalized peritonitis and severe abdominal signs. Many times these patients come back after discharge from the hospital with signs of peritonitis and fever. These patients are morbidly sick and an optimal treatment plan is required. Evaluation with ultrasonography (3D), CT scan and MRI usually indicate the extent of the infection and soft tissue injuries like uterine incision dehiscence or breakdown. Broad spectrum parenteral antibiotics after sample collection for cultures are started. Fluid electrolyte imbalances are corrected. Blood gas analysis and their correction is required. Correction of anemia by transfusion of packed red blood cellss may also be needed. Large abdominal generalized collections usually require drainage. In a very moribund patient ultrasonography guided drains may be inserted. However, it is more prudent to perform an exploratory laparotomy, drain the collection, perform peritoneal lavage, insert drains. If the uterine incision has broken down it may not be possible to repair it in the presence of overwhelming infection. Loose hanging, broken sutures should be excised and the edges freshened. It may be a difficult decision to defer closure of the uterine wound. However, if the tissue is not friable which it usually is then uterine incision may be closed with interrupted sutures as continuous sutures may cut through the friable tissue. Choice of suture material should be a non reactive, mono-filament, delayed absorbable suture like PDS. However, if the tissue is very friable then a decision for closure of the abdomen without suturing the uterus with placement of intra-peritoneal drains or a hysterectomy may have to be considered (a preoperative counseling and consent should be obtained). Hysterectomy would further add to the morbidity as it would open up tissue planes and provide a path for the spread of the infection. Once the patient stabilizes then the uterine incision may be seen to have healed by secondary intention by imaging techniques. In these cases of deep wound infection the integrity of the scar is suspect and the patient should be warned against future pregnancies or counseled regarding the grave but a real risk of scar rupture or dehiscence and its associated consequences for self and for her baby. Such advise and counseling should be properly documented in her case record for future reference.
Overuse of cesarean deliveries, lifestyle changes resulting in obesity, diabetes, casual attitude towards aseptic precautions, poor infection control surveillance all form a perfect recipe for postoperative cesarean sepsis.

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